Individual Therapy Intake Form

Thank you for taking the time to complete the intake form for your child’s therapy services at Momentum. We appreciate the opportunity to support your child’s development and look forward to partnering with you in their journey.

Our team will review the information you provided and follow up with you within 1 business day regarding the next steps. If you have any questions in the meantime, please don’t hesitate to reach out to us at MPTNIntake@momentum4all.org or (310) 328-0276.

We are honored to be part of your child’s care team and look forward to working together to help them thrive!

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Parent/Guardian Information

Parent/Guardian's First and Last Name*

As listed on your child's medical paperwork

Parent/Guardian Email*

What is the best email to reach you at?

What is the best phone number to reach you at?*

Phone

Electronic Communication*

Email, texting, and videoconferencing are popular and convenient ways to communicate. However, text messages sent via standard SMS/Apple iMessage, and emails sent via popular email services are not encrypted or secured. This means a third party may be able to intercept or access the information and read it since it was transmitted in an unsecured and unencrypted manner. In addition, most popular forms of videoconference do not utilize secured lines of communication. This means that a third party may be able to intercept or access the transmission or information. HIPPA guidelines state that if a patient has been made aware of the risks of unencrypted electronic communications, and that same patient provides consent to receive health information via electronic communication, then a health entity may send that patient personal medical information via unencrypted electronic means. In light of the above information and advisory related to unsecured and unencrypted electronic communication, please review the following and sign the options you prefer: Allow Unencrypted Email- I understand that emails are not confidential methods of communication and may be insecure. I further understand the risks of unencrypted email and do hereby give permission to Momentum to send me personal health information via unencrypted email.

Select all that you give Momentum permission to communicate with you regarding your child's services:

Text Message

None

Child's Information

Child's First and Last Name*

Please enter their name as it appears on their insurance card

Child's Date of Birth*

Please confirm you've entered the correct year.

What Therapy Services are you interested in for your child?*

select all that apply

Select

What days is your child available for services?*

Select

What times work best for your family?*

Select

Insurance and Funding

What funding source(s) will you be using to pay for therapy services?*

Select

What Insurance provider(s) does your child have?*

For example: Aetna PPO, Kaider, Healthnet HMO w/ Memorial Care, Optum, etc.

File Upload*

To help expedite the process and ensure a smooth start to services, please upload a photo or copy of your child’s insurance card (front and back).

Optional: Please upload a photo or copy of any referrals and/or authorizations you have received from your provider.

Drag and drop files here or

Tell us more about your concerns regarding your child's development?*

How did you hear about our servces?*

Select

Notes or Comments

Is there anything else you would like for our team to know?

Send me a copy of my responses

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